Periodontal Case #4 - Necrotizing Ulcerative Periodontitis
Our patient today is Sean Johnson, he is a 21 year old single Male Caucasian DOB 4-21-1990 and is here to have his oral health evaluated. Sean has generalized pain and is concerned about the way his gums look and the foul odor, he believes he is having an episode of a previously diagnosed condition called NUG.Sean has a history of generalized spontaneous bleeding since he started his college studies and more frequently since he started the Physicians Assistant Program last Fall (Sept. 2010) to the present. He also complains of pain when brushing his teeth. He has generalized sensitivity to cold temperatures. Sean had orthodontic braces from 2004 to 2006 and has worn his removable retainers on and off since removal of his orthodontic treatment, but stopped wearing them about 6 months ago; he complains that his mouth hurts too much to wear them and they bother him. Sean is concerned of his lower right molar area teeth feeling loose and this area has been hurting but cannot discern if it’s his actual teeth or the gums that hurt; he stated it feels like both. Since he started the Physicians Assistant Program last year he has been waking up with his jaw feeling sore and believes he may be clenching or grinding when he is asleep and relates it to the stress he is under from his studies.Sean used to get his teeth cleaned every 6 months since he was a child and as a teenager but since he started college as an 18 year old, his cleanings became infrequent and he also stopped flossing and brushing regularly like he used to. He stated that he is too busy with school and doesn’t find the time to go to the dentist anymore or take care of his oral health. His last cleaning was July 2008, at that time he went in on an emergency basis because of his gums being very red and painful. The dentist at that time diagnosed him with NUG and treated him the following week after he had a medical consultation with his medical physician to rule out any condition that may contribute to an altered host immune response and rule out any hematologic disease. Sean stated he never went back to that dentist for a follow up nor further treatment. Sean had an FMX in February 1999. Patient stated that he has been having problems with his teeth and gums for the past 2 years, but his condition comes and goes and he just hasn’t had the time to go to the dentist to resolve this issue. He stated that the pain is too unbearable now and it is affecting his ability to be successful at school.Sean has no past or present history of any cardiovascular conditions, respiratory conditions, head and neck conditions. He drinks beer on the weekends and admits that it’s in excess, but no history of drug use. Sean smokes a pack of cigarettes a day and started smoking in high school when he was 16 years old. Sean doesn’t have any intentions of quiting; he stated it helps him focus on his studies and he forgets to eat or doesn’t have time to eat, so he smokes a cigarette and it makes him feel better.There is no past or present history of neuromuscular/CNS conditions. For gastrointestinal/genito/urinary history, Sean had gonorrhea and was treated successfully in 2009 with antibiotics and it resolved. There is no past or present history of hema/endo/immune disorders, psychological disorders and had his child vaccinations as a child, including hepatitis B vaccination series in 2006. Sean has never had a flu shot. Sean has a family history of bleeding disorders; his paternal grandmother had VonWillebrand disorder, is now deceased. Sean has no allergies to any medications or products. Sean stated he has not been to his regular physician since high school and has no other medical history to share. Sean has no history of emergency room visits or hospitalizations. He is not taking any medications nor supplements.S: Pt. stated he is here for, “to have his oral health evaluated; has generalized pain and is concerned about the way his gums look.”
O: RMH Initial visit, B.P.116/75 , P.78 , R.17 , E & I bilaterally pharyngeal arches erythematous and pt complain of sore itchy feeling in his throat. Bilaterally tonsils palpable. Pt stated he has been feeling really run down and tired for several months now, but hasn’t been to the doctor for it.A: ASA I, ADA II with localized ADA III on #31. AAP class Acute necrotizing ulcerative periodontitis. MVC Cal Code light/medium .
P: Gathered assessments, took 18 film FMX, DDS Exam, 2nd check-in, PI 12%, OHI discussed; gave pt extra soft toothbrush and demonstrated modified bass method. Gave pt interdental brush and recommended he dip it into Chlorehexidine. Local debridement and scaling & root planing done on all 4 quads. Used anesthesia on all quads for sensitivity and used chlorehexidine as adjunct antimicrobial irrigation therapy. NV: 4-6 Re-eval E & I: bilaterally pharyngeal arches erythematous and pt complain of sore itchy feeling in his throat. Bilaterally tonsils palpable. Pt stated he has been feeling really run down and tired for several months now, but hasn’t been to the doctor for it.
Salivary Flow: adequate.
TMD findings: none.
Max. opening: 51 mm.
Facial profile: mesognathic.
Angles class: bilaterally class II.
Gingival description:
Attached: generalized pink, shiny, and flaccid.
Free: generalized grayish, necrotic, blunted, and sloughing with an appearance of “punched out” papillae. MBI: 60%
Perio exam: Generalized probing depths of 3-4, BOP 55 %. Rescesion: 2 mm on buccal of #2-3, 13-14, and 31. 3 mm on buccal and lingual of 6-11, 22-27. Furcations: class I direct buccal #2, 14, 31.
Mobility: Class I #6-11 and #22, #27. Class II on # 23-26.
Fremitus: +#6-9.
Mucogingival problems: # 26-28 have 1mm defect on the buccal. Frenal pull noted.
OHA Status: poor. DDS EXAM: Missing teeth and reason & impacted teeth: #1,16, 17, 32 missing, extracted for ortho tx.
Existing Restorations: #2 MO amal, #15 DO amal, #21 O composite. Margins intact.
Possible areas of decay intraorally: #20 O, #14 O.
Radiographic Possible areas of decay: #14D, 15M. Atypical FindinDgs: generalzied attrition noted on mandibular anterior teeth.
Radiolucencies on apices: none. Intrinsic/Extrinsic Resorption: none. Root Resorption: none. Dilacerated Roots: none. Other Atypical Anatomy Findings: none. Radiolucent/Radiopaque lesions/Foreign Objects: none. 2nd check in: Periodontal Interpretation State quality of radiographs: Adequate.
Trabecular Pattern: consistant.
Lamina Dura: generalized fuzzy at interdental papilla.
Alveolar Crest: generalized 3-4 mm from CEJ with localized vertical defect on mesial of #31 with 4-5 mm alveolar crest from CEJ. PDL Space: is consistent throughout with localized widening on the mandibular anterior teeth #23-26 and mesial of #31.
Interradicular Radiolucency: #2, 14, 31.
Calculus Noted: none.
Osseous Interp: consistent.
ADA class: ADA II with localized ADA III on #31. AAP class: Acute necrotizing ulcerative periodontitis.
MVC Cal. Code (type is grainy and location is molar regions and lower anteriors): Light/MediumPresented critical thinking and treatment plan. Pt. agreed and signed treatment plan.
CRITICAL THINKING – TREATMENT PLANNING Moreno Valley College Student:_Sides, Yanez, Starnes Dental Hygiene Program Date: _10-03-2011 Patient’s Chart #:__4120_ CHIEF COMPLAINT:Pt. stated he is here for, “to have his oral health evaluated; has generalized pain and is concerned about the way his gums lookand foul odor.”_
MEDICAL HISTORY/ SYSTEMIC HEALTH:Tobacco use
ORAL RISK FACTORS:Xerostomia Periodontitis Increased risk for caries
DENTAL HEALTH DIAGNOSIS:
Perio: Controlled Uncontrolled X
Caries : Controlled_ Uncontrolled_X
Oral Hygiene: Controlled_ Uncontrolled _X
Influencing Cultural and Social Factors: in a rigorous, stressful Physician Assistant program, feels appearance and pain his gums give him may contribute to his recent inability to perform well in school, feels he has no time to take care of his teeth.
DENTAL HYGIENE CARE PLAN:
Oral Health Education/Strategies1. Oral Health Belief Model- Pt believes that Periodontitis is a serious condition and believes that he is susceptible to the disease and is willing to change his homecare to improve the health of gums. 2. Recommended OHI- use extra soft toothbrush and bass method 2x a day. Interdental brush 2x a day dipped in CHX, Rinse w/ CHX 1x a day.
Anesthesia/Rationale-Yes overall tenderness and sensitivity when manipulating gingiva
Reevaluations (ex Hard and soft tissue):_ulcerative, gray pseudomembrane covering all interdental papilla and free gingival.ANTICIPATED TREATMENT OUTCOMES:_reduce MBI and BOP by 10%___
Our patient today is Sean Johnson, he is a 21 year old single Male Caucasian DOB 4-21-1990 and is here to have his oral health evaluated. Sean has generalized pain and is concerned about the way his gums look and the foul odor, he believes he is having an episode of a previously diagnosed condition called NUG.Sean has a history of generalized spontaneous bleeding since he started his college studies and more frequently since he started the Physicians Assistant Program last Fall (Sept. 2010) to the present. He also complains of pain when brushing his teeth. He has generalized sensitivity to cold temperatures. Sean had orthodontic braces from 2004 to 2006 and has worn his removable retainers on and off since removal of his orthodontic treatment, but stopped wearing them about 6 months ago; he complains that his mouth hurts too much to wear them and they bother him. Sean is concerned of his lower right molar area teeth feeling loose and this area has been hurting but cannot discern if it’s his actual teeth or the gums that hurt; he stated it feels like both. Since he started the Physicians Assistant Program last year he has been waking up with his jaw feeling sore and believes he may be clenching or grinding when he is asleep and relates it to the stress he is under from his studies.Sean used to get his teeth cleaned every 6 months since he was a child and as a teenager but since he started college as an 18 year old, his cleanings became infrequent and he also stopped flossing and brushing regularly like he used to. He stated that he is too busy with school and doesn’t find the time to go to the dentist anymore or take care of his oral health. His last cleaning was July 2008, at that time he went in on an emergency basis because of his gums being very red and painful. The dentist at that time diagnosed him with NUG and treated him the following week after he had a medical consultation with his medical physician to rule out any condition that may contribute to an altered host immune response and rule out any hematologic disease. Sean stated he never went back to that dentist for a follow up nor further treatment. Sean had an FMX in February 1999. Patient stated that he has been having problems with his teeth and gums for the past 2 years, but his condition comes and goes and he just hasn’t had the time to go to the dentist to resolve this issue. He stated that the pain is too unbearable now and it is affecting his ability to be successful at school.Sean has no past or present history of any cardiovascular conditions, respiratory conditions, head and neck conditions. He drinks beer on the weekends and admits that it’s in excess, but no history of drug use. Sean smokes a pack of cigarettes a day and started smoking in high school when he was 16 years old. Sean doesn’t have any intentions of quiting; he stated it helps him focus on his studies and he forgets to eat or doesn’t have time to eat, so he smokes a cigarette and it makes him feel better.There is no past or present history of neuromuscular/CNS conditions. For gastrointestinal/genito/urinary history, Sean had gonorrhea and was treated successfully in 2009 with antibiotics and it resolved. There is no past or present history of hema/endo/immune disorders, psychological disorders and had his child vaccinations as a child, including hepatitis B vaccination series in 2006. Sean has never had a flu shot. Sean has a family history of bleeding disorders; his paternal grandmother had VonWillebrand disorder, is now deceased. Sean has no allergies to any medications or products. Sean stated he has not been to his regular physician since high school and has no other medical history to share. Sean has no history of emergency room visits or hospitalizations. He is not taking any medications nor supplements.S: Pt. stated he is here for, “to have his oral health evaluated; has generalized pain and is concerned about the way his gums look.”
O: RMH Initial visit, B.P.116/75 , P.78 , R.17 , E & I bilaterally pharyngeal arches erythematous and pt complain of sore itchy feeling in his throat. Bilaterally tonsils palpable. Pt stated he has been feeling really run down and tired for several months now, but hasn’t been to the doctor for it.A: ASA I, ADA II with localized ADA III on #31. AAP class Acute necrotizing ulcerative periodontitis. MVC Cal Code light/medium .
P: Gathered assessments, took 18 film FMX, DDS Exam, 2nd check-in, PI 12%, OHI discussed; gave pt extra soft toothbrush and demonstrated modified bass method. Gave pt interdental brush and recommended he dip it into Chlorehexidine. Local debridement and scaling & root planing done on all 4 quads. Used anesthesia on all quads for sensitivity and used chlorehexidine as adjunct antimicrobial irrigation therapy. NV: 4-6 Re-eval
E & I: bilaterally pharyngeal arches erythematous and pt complain of sore itchy feeling in his throat. Bilaterally tonsils palpable. Pt stated he has been feeling really run down and tired for several months now, but hasn’t been to the doctor for it.
Salivary Flow: adequate.
TMD findings: none.
Max. opening: 51 mm.
Facial profile: mesognathic.
Angles class: bilaterally class II.
Gingival description:
Attached: generalized pink, shiny, and flaccid.
Free: generalized grayish, necrotic, blunted, and sloughing with an appearance of “punched out” papillae. MBI: 60%
Perio exam: Generalized probing depths of 3-4, BOP 55 %. Rescesion: 2 mm on buccal of #2-3, 13-14, and 31. 3 mm on buccal and lingual of 6-11, 22-27. Furcations: class I direct buccal #2, 14, 31.
Mobility: Class I #6-11 and #22, #27. Class II on # 23-26.
Fremitus: +#6-9.
Mucogingival problems: # 26-28 have 1mm defect on the buccal. Frenal pull noted.
OHA Status: poor. DDS EXAM: Missing teeth and reason & impacted teeth: #1,16, 17, 32 missing, extracted for ortho tx.
Existing Restorations: #2 MO amal, #15 DO amal, #21 O composite. Margins intact.
Possible areas of decay intraorally: #20 O, #14 O.
Radiographic Possible areas of decay: #14D, 15M. Atypical FindinDgs: generalzied attrition noted on mandibular anterior teeth.
Radiolucencies on apices: none. Intrinsic/Extrinsic Resorption: none. Root Resorption: none. Dilacerated Roots: none. Other Atypical Anatomy Findings: none. Radiolucent/Radiopaque lesions/Foreign Objects: none. 2nd check in: Periodontal Interpretation State quality of radiographs: Adequate.
Trabecular Pattern: consistant.
Lamina Dura: generalized fuzzy at interdental papilla.
Alveolar Crest: generalized 3-4 mm from CEJ with localized vertical defect on mesial of #31 with 4-5 mm alveolar crest from CEJ. PDL Space: is consistent throughout with localized widening on the mandibular anterior teeth #23-26 and mesial of #31.
Interradicular Radiolucency: #2, 14, 31.
Calculus Noted: none.
Osseous Interp: consistent.
ADA class: ADA II with localized ADA III on #31. AAP class: Acute necrotizing ulcerative periodontitis.
MVC Cal. Code (type is grainy and location is molar regions and lower anteriors): Light/MediumPresented critical thinking and treatment plan. Pt. agreed and signed treatment plan.
CRITICAL THINKING – TREATMENT PLANNING
Moreno Valley College Student:_Sides, Yanez, Starnes
Dental Hygiene Program Date: _10-03-2011
Patient’s Chart #:__4120_
CHIEF COMPLAINT:Pt. stated he is here for, “to have his oral health evaluated; has generalized pain and is concerned about the way his gums lookand foul odor.”_
Perio: Controlled Uncontrolled X
Caries : Controlled_ Uncontrolled_X
Oral Hygiene: Controlled_ Uncontrolled _X
Instructor Signature:D. Lesser_
Treatment Plan:__
Appt. #1
Assessments
X-ray Check
DDS Exam
2nd Check-in
PI/OHI
URQ, LRQ, ULQ, LLQ Debridement
LRQ scale & root plan w/ anesthesia (IA/Buccal 1.8 2% Lido w/Epi)
Fluoride Varnish Treatment
Appt #2
OHI
4-6 Week Re-eval
Appt #3
2 Month Recare
FM Scale
Fl Tx
OHI